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Economist: Chronic Diseases

Chronic diseases in developing countries

Growing pains

Poor countries are developing the diseases of the rich, with lethal consequences

Sep 24th 2011 | KAMPALA AND NEW YORK | from the print edition

 

THE Uganda Cancer Institute is on a hilltop with a fine view of the verdant capital, Kampala. But most of its patients are too ill to stand. They have spent their life’s savings for a chance of a cure, but most die within weeks of being admitted. “They come too late,” says Jackson Orem, the clinic’s director.

Of Ugandans who die of cancer, 96% never see a medical practitioner. The country’s health-care system was designed to treat infectious diseases: the institute’s neighbour is a big tuberculosis unit. Non-communicable diseases such as cancer, diabetes, and heart and respiratory ailments have not been priorities. Dr Orem’s institute has the only cancer unit for the country’s 34m people. Kidney failure (a result of diabetes) is a death warrant. Uganda has only seven dialysis machines. The cheapest transplant (in India) costs $40,000.

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• »Growing pains
• Dying out

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Time was when people in poor countries were too hungry and hardworking to be obese, could not afford cigarettes and mostly died before the ailments of ripe middle age kicked in. Non-communicable diseases were a rich-world problem. Not any more. Affluence and urbanisation mean new kinds of unhealthy lifestyles. Developing countries already bear more than 80% of the burden of chronic illnesses. Their share will grow—at a time when older diseases are still ravaging the poor. In India over two-fifths of children under five are malnourished, yet obesity is mushrooming. The leader of the main opposition party, Nitin Gadkari, is the latest public figure to be fitted with a gastric band.

Old and new diseases compound each other. Diabetics are three times as likely to contract tuberculosis. Burkitt’s lymphoma, a cancer common in equatorial Africa, is linked to malaria. HIV patients on antiretroviral treatment are at a higher risk of developing diabetes and cancer. Two-thirds of Mr Orem’s cancer patients in Uganda also have HIV. “None of the HIV resources went to cancer—a very big mistake,” he says. Julio Frenk, dean of the Harvard School of Public Health, highlights the contradiction between spending thousands of dollars on each patient with AIDS but not offering “pennies” for those with diabetes.

The World Health Organisation expects deaths from non-communicable diseases to rise by 15% between 2010 and 2020, with jumps of over 20% in Africa and South-East Asia. The number of Chinese diabetics is expected to double by 2025. Even in sub-Saharan Africa, chronic illnesses are likely to surpass maternal, child and infectious diseases as the biggest killer by 2030. Most of them stem from sugar, fat, smoke and sedentary lifestyles. But they also include sickle-cell disease, a blood disorder that is the biggest non-communicable killer of Africa’s children. It is easily treatable, but almost always goes undiagnosed.

The countries concerned are woefully unprepared. Their health-care systems are designed for acute problems, not least because that is what foreign donors pay for. Less than 3% of aid for health goes to chronic illnesses. Many patients without health insurance delay treatment until it is too late. Many of the drugs needed are no longer covered by patents, but tariffs, poor distribution and high mark-ups still make them costly and scarce. The demands on health authorities are also greater. The right jab can protect a child for life, but chronic diseases may require lifelong medication. A big cause of diabetes is unhealthy diet—but that stems from a complex overlap between brain chemistry and food-industry practice. Even rich countries find this hard to change.

 

A feeble response ensures that non-communicable diseases kill people earlier in poor countries than in rich ones. This has a grave impact not just on health, but on growth. According to the World Economic Forum, poor and middle-income countries will lose $7.3 trillion in output from heart disease, cancer, diabetes and lung disease by 2025 (see chart)—an annual loss of about 4%.

So far the world’s response has been to have meetings, most recently a UN summit in New York on September 19th-20th. The only other summit devoted to health was on HIV in 2001. A sense of crisis then brought a decade of dramatic progress. Heart disease does not arouse the same passion. The meeting passed a “political declaration”, but could not agree on targets for reducing non-communicable diseases. The declaration’s wording on drugs was opaque, reflecting stalled negotiations.

With no clear global lead, countries muddle along. Mr Orem’s institute in Kampala spends most of its money on drugs. He says a budget rise from $2.5m to $8m would help to train nurses and improve palliative care. But money is scarce and even the simplest tasks are tricky. It can take a month for a patient outside Kampala to get results from a biopsy.

Ala Alwan of the World Heath Organisation suggests that even simple steps can make a difference, such as reducing salt in foods, offering inexpensive drugs and raising tobacco taxes. This last is perhaps the single best way of curbing cancer and diseases of the heart and lungs, as well as raising money for health care. But James Sekajugo of the Ugandan health ministry says it is hard to fight the tobacco industry: “a very rich group here”. His country is trying to stop cancer before it starts. The ministry is considering spending more on vaccines against cervical cancer, one of the most deadly cancers for women.

Some hope to build on arrangements in place for treating HIV (itself now a chronic condition, not a death sentence). A programme in western Kenya called AMPATH once treated only HIV patients. Now it offers care for those with such illnesses as cancer and diabetes. Its door-to-door screening programme for HIV now tests for blood pressure and blood sugar. America’s PEPFAR (the President’s Emergency Plan for AIDS Relief), is trying to fight HIV by boosting broader health care.

The most sustainable efforts will be those that provide care and make money, too. In India Dr Mohan’s Diabetes Centres, a business, charges middle-class patients to subsidise care for the poor. Eli Lilly, an American pharmaceutical giant, is testing models for diabetes treatment in countries such as India, South Africa and Brazil (it also provides free insulin to AMPATH in Kenya). Help now, it reckons, and profit later. Novo Nordisk, the world’s biggest insulin manufacturer, is especially ambitious. In China it has given training to doctors and education for diabetics. Last year the firm controlled 63% of China’s insulin market. Now Lars Rebien Sorensen, its chief executive, wants to replicate the programme in Indonesia, Malaysia and Vietnam. Chronic diseases are already a huge market. Sadly, it is also a growing one.

from the print edition | International

Economist: Dogs and Humans

 

Rather, their emotional range is more limited than ours, partly because, with little sense of time, they are trapped almost entirely in the present. Dogs can experience joy, anxiety and anger. But emotions that demand a capacity for self-reflection, such as guilt or jealousy, are almost certainly beyond them, contrary to the convictions of many dog owners.

Mr Bradshaw believes that it is difficult for people to empathise with the way in which dogs experience and respond to the world through their extraordinary sense of smell: their sensitivity to odours is between 10,000 and 100,000 times greater than ours. A newly painted room might be torture for a dog; on the other hand, their olfactory ability and their trainability allow dogs to perform almost unimaginable feats, such as smelling the early stages of a cancer long before a normal medical diagnosis would detect it.

==

 

Human beings and dogs

Man’s best friend

Scientific research throws new light on a very old partnership

Aug 6th 2011 | from the print edition

 

Dog Sense: How the New Science of Dog Behaviour Can Make You a Better Friend to Your Pet. By John Bradshaw. Basic Books; 324 pages; $25.99. Published in Britain as “In Defence of Dogs: Why Dogs Need Our Understanding”. Allen Lane; £20. Buy from Amazon.com, Amazon.co.uk

THE relationship between people and dogs is unique. Among domesticated animals, only dogs are capable of performing such a wide variety of roles for humans: herding sheep, sniffing out drugs or explosives and being our beloved companions. It is hard to be precise about when the friendship began, but a reasonable guess is that it has been going strong for more than 20,000 years. In the Chauvet cave in the Ardèche region of France, which contains the earliest known cave paintings, there is a 50-metre trail of footprints made by a boy of about ten alongside those of a large canid that appears to be part-wolf, part-dog. The footprints, which have been dated by soot deposited from the torch the child was carrying, are estimated to be about 26,000 years old.

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• Correction: Reinhold Niebuhr
• Star Spangled Man
• »Man’s best friend
• Cat got your tongue?
• Gathered in the marketplace
• Songwriter shot dead

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The first proto-dogs probably remained fairly isolated from each other for several thousand years. As they became progressively more domesticated they moved with people on large-scale migrations, mixing their genes with other similarly domesticated creatures and becoming increasingly dog-like (and less wolf-like) in the process. For John Bradshaw, a biologist who founded the anthrozoology department at the University of Bristol, having some idea about how dogs got to be dogs is the first stage towards gaining a better understanding of what dogs and people mean to each other. Part of his agenda is to explode the many myths about the closeness of dogs to wolves and the mistakes that this has led to, especially in the training of dogs over the past century or so.

One idea has governed dog training for far too long, Mr Bradshaw says. Wolf packs are supposedly despotic hierarchies dominated by alpha wolves. Dogs are believed to behave in the same way in their dealings with humans. Thus training a dog effectively becomes a contest for dominance in which there can be only one winner. To achieve this the trainer must use a variety of punishment techniques to gain the dog’s submission to his mastery. Just letting a dog pass through a door before you or stand on the stairs above you is to risk encouraging it to believe that it is getting the upper hand over you and the rest of the household. Mr Bradshaw argues that the theory behind this approach is based on bad and outdated science.

Dogs share 99.6% of the same DNA as wolves. That makes dogs closer to wolves than we are to chimps (with which we have about 96% of our DNA in common), but it does not mean that their brains work like those of wolves. Indeed, the outgoing affability of most dogs towards humans and other dogs is in sharp contrast to the mix of fear and aggression with which wolves react to animals from other packs. “Domestication has been a long and complex process,” Mr Bradshaw writes. “Every dog alive today is a product of this transition. What was once another one of the wild social canids, the grey wolf, has been altered radically, to the point that it has become its own unique animal.” If anything, dogs resemble juvenile rather than fully adult canids, a sort of arrested development which accounts for the way they remain dependent on their human owners throughout their lives.

But what makes the dog-wolf paradigm especially misleading, Mr Bradshaw argues, is that until recently, the studies of wolves were of the wrong wolves in extremely artificial conditions. In the wild, wolf packs tend to be made up of close family members representing up to three generations. The father and mother of the first lot of cubs are the natural leaders of the pack, but the behavioural norm is one of co-operation rather than domination and submission. However, the wolves on which biologists founded their conclusions about dominance hierarchies were animals living in unnaturally constituted groups in captivity. Mr Bradshaw says that feral or “village” dogs, which are much closer to the ancestors of pet dogs than they are to wolves, are highly tolerant of one another and organise themselves entirely differently from either wild or captive wolves.

Dogs are not like nicely brought-up wolves, says the author, nor are they much like people despite their extraordinary ability to enter our lives and our hearts. This is not to deny that some dogs are very clever or that they are capable of feeling emotion deeply. But their intelligence is different from ours. The idea that some dogs can understand as many words as a two-year-old child is simply wrong and an inappropriate way of trying to measure canine intellect. Rather, their emotional range is more limited than ours, partly because, with little sense of time, they are trapped almost entirely in the present. Dogs can experience joy, anxiety and anger. But emotions that demand a capacity for self-reflection, such as guilt or jealousy, are almost certainly beyond them, contrary to the convictions of many dog owners.

Mr Bradshaw believes that it is difficult for people to empathise with the way in which dogs experience and respond to the world through their extraordinary sense of smell: their sensitivity to odours is between 10,000 and 100,000 times greater than ours. A newly painted room might be torture for a dog; on the other hand, their olfactory ability and their trainability allow dogs to perform almost unimaginable feats, such as smelling the early stages of a cancer long before a normal medical diagnosis would detect it.

The latest scientific research can help dogs and their owners have happier, healthier relationships by encouraging people to understand dogs better. But Mr Bradshaw is also fearful. In particular, he deplores the incestuous narrowing of the gene pool that modern pedigree breeders have brought about. Dogs today are rarely bred for their working abilities (herding, hunting, guarding), but for a very particular type of appearance, which inevitably risks the spread of physical and temperamental abnormalities. Instead, he suggests that dogs be bred for the ideal behavioural traits associated with the role they will actually play. He also worries that the increasing urbanisation of society and the pressures on couples to work long hours are putting dogs under huge strain. He estimates that about 20% of Britain’s 8m dogs and America’s 70m suffer from “separation distress” when their owners leave the house, but argues that sensible training can teach them how to cope.

“Dog Sense” is neither a manual nor a sentimental account of the joys of dog-ownership. At times its rigorously research-led approach can be slightly heavy going. A few more jolly anecdotes might have leavened the mix. But this is a wonderfully informative, quietly passionate book that will benefit every dog whose owner reads it.

from the print edition | Books and Arts

FT: Pharma: study spreads heartache

Pharma: study spreads heartache

Published: May 30 2011 19:16 | Last updated: May 30 2011 19:16

Everyone wants it to be causation, but it may be correlation. People with elevated high-density lipoprotein (“good”) cholesterol are less likely to die of heart disease. So, one would think, pills that raise HDL cholesterol will reduce deaths. A study released last week by the US National Institutes of Health suggests they might not. The drug studied was Niaspan, a time-release formulation of vitamin B3. Niaspan does raise HDL cholesterol, but the trial was halted because patients who took it, along with a bad-cholesterol lowering drug, did not have fewer cardiovascular problems than the control group.

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Drug companies have wagered billions on good cholesterol. Abbott Labs paid $3.7 billion for Niaspan in 2006, when it bought Kos Pharma. The drug had over $900m in sales last year. Merck, Roche and Lilly have HDL drugs in development, and Pfizer invested massively in another that failed because of side effects.

More study may revive the causal link between good cholesterol and mortality. But the NIH study is another in a string of scientific disappointments for the drug industry. Bulls compare the single-digit price to earnings multiples many drug companies carry today with the twenty-plus multiples of the 1990s. There is more top-line pressure from patent expirations now, but is the correction overdone? It depends on what the normal amount of pipeline success is. The 1990s brought highly effective drugs for heart disease, depression, psychosis, allergies, hypertension, HIV, and diabetes. Since then, big successes have been rare. If the last decade represents the new normal, pharma stocks are correctly priced at best. An even partial return to the good old days turns them into bargains. The question is whether betting on the path of science makes sense. There may be drug firms worth buying; predicting a sector recovery would be hubris.

E-mail the Lex team in confidence at lex@ft.com

Copyright The Financial Times Limited 2011

Economist: Alternative medicine, Placebos

Alternative medicine

Think yourself better

Alternative medical treatments rarely work. But the placebo effect they induce sometimes does

May 19th 2011 | from the print edition

ON MAY 29th Edzard Ernst, the world’s first professor of complementary medicine, will step down after 18 years in his post at the Peninsula Medical School, in south-west England. Despite his job title (and the initial hopes of some purveyors of non-mainstream treatments), Dr Ernst is no breathless promoter of snake oil. Instead, he and his research group have pioneered the rigorous study of everything from acupuncture and crystal healing to Reiki channelling and herbal remedies.

Alternative medicine is big business. Since it is largely unregulated, reliable statistics are hard to come by. The market in Britain alone, however, is believed to be worth around £210m ($340m), with one in five adults thought to be consumers, and some treatments (particularly homeopathy) available from the National Health Service. Around the world, according to an estimate made in 2008, the industry’s value is about $60 billion.

Over the years Dr Ernst and his group have run clinical trials and published over 160 meta-analyses of other studies. (Meta-analysis is a statistical technique for extracting information from lots of small trials that are not, by themselves, statistically reliable.) His findings are stark. According to his “Guide to Complementary and Alternative Medicine”, around 95% of the treatments he and his colleagues examined—in fields as diverse as acupuncture, herbal medicine, homeopathy and reflexology—are statistically indistinguishable from placebo treatments. In only 5% of cases was there either a clear benefit above and beyond a placebo (there is, for instance, evidence suggesting that St John’s Wort, a herbal remedy, can help with mild depression), or even just a hint that something interesting was happening to suggest that further research might be warranted.

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It was, at times, a lonely experience. Money was hard to come by. Practitioners of alternative medicine became increasingly reluctant to co-operate as the negative results piled up (a row in 2005 with an alternative-medicine lobby group founded by Prince Charles did not help), while traditional medical-research bodies saw investigations into things like Ayurvedic healing as a waste of time.

Yet Dr Ernst believes his work helps address a serious public-health problem. He points out that conventional medicines must be shown to be both safe and efficacious before they can be licensed for sale. That is rarely true of alternative treatments, which rely on a mixture of appeals to tradition and to the “natural” wholesomeness of their products to reassure consumers. That explains why, for instance, some homeopaths can market treatments for malaria, despite a lack of evidence to suggest that such treatments work, or why some chiropractors can claim to cure infertility.

Despite this lack of evidence, and despite the possibility that some alternative practitioners may be harming their patients (either directly, or by convincing them to forgo more conventional treatments for their ailments), Dr Ernst also believes there is something that conventional doctors can usefully learn from the chiropractors, homeopaths and Ascended Masters. This is the therapeutic value of the placebo effect, one of the strangest and slipperiest phenomena in medicine.

Mind and body

A placebo is a sham medical treatment—a pharmacologically inert sugar pill, perhaps, or a piece of pretend surgery. Its main scientific use at the moment is in clinical trials as a baseline for comparison with another treatment. But just because the medicine is not real does not mean it doesn’t work. That is precisely the point of using it in trials: researchers have known for years that comparing treatment against no treatment at all will give a misleading result.

Giving pretend painkillers, for instance, can reduce the amount of pain a patient experiences. A study carried out in 2002 suggested that fake surgery for arthritis in the knee provides similar benefits to the real thing. And the effects can be harmful as well as helpful. Patients taking fake opiates after having been prescribed the real thing may experience the shallow breathing that is a side-effect of the real drugs.

Besides being benchmarks, placebos are a topic of research in their own right. On May 16th the Royal Society, the world’s oldest scientific academy, published a volume of its Philosophical Transactions devoted to the field.

One conclusion emerging from the research, says Irving Kirsch, a professor at Harvard Medical School who wrote the preface to the volume, is that the effect is strongest for those disorders that are predominantly mental and subjective, a conclusion backed by a meta-analysis of placebo studies that was carried out in 2010 by researchers at the Cochrane Collaboration, an organisation that reviews evidence for medical treatments. In the case of depression, says Dr Kirsch, giving patients placebo pills can produce very nearly the same effect as dosing them with the latest antidepressant medicines.

Pain is another nerve-related symptom susceptible to treatment by placebo. Here, patients’ expectations influence the potency of the effect. Telling someone that you are giving him morphine provides more pain relief than saying you are dosing him with aspirin—even when both pills actually contain nothing more than sugar. Neuro-imaging shows that this deception stimulates the production of naturally occurring painkilling chemicals in the brain. A paper in Philosophical Transactions by Karin Meissner of Ludwig-Maximilians University in Munich concludes that placebo treatments are also able to affect the autonomic nervous system, which controls unconscious functions such as heartbeat, blood pressure, digestion and the like. Drama is important, too. Placebo injections are more effective than placebo pills, and neither is as potent as sham surgery. And the more positive a doctor is when telling a patient about the placebo he is prescribing, the more likely it is to do that patient good.

Despite the power of placebos, many conventional doctors are leery of prescribing them. They worry that to do so is to deceive their patients. Yet perhaps the most fascinating results in placebo research—most recently examined by Ted Kaptchuk and his colleagues at Harvard Medical School, in the context of irritable-bowel syndrome—is that the effect may persist even if patients are told that they are getting placebo treatments.

Unlike their conventional counterparts, practitioners of alternative medicine often excel at harnessing the placebo effect, says Dr Ernst. They offer long, relaxed consultations with their customers (exactly the sort of “good bedside manner” that harried modern doctors struggle to provide). And they believe passionately in their treatments, which are often delivered with great and reassuring ceremony. That alone can be enough to do good, even though the magnets, crystals and ultra-dilute solutions applied to the patients are, by themselves, completely useless.

from the print edition | Science and Technology

Medicine

There is no alternative

Virtually all alternative medicine is bunk; but the placebo effect is rather interesting

May 19th 2011 | from the print edition